Appendix

- Attitudes and behaviors of Japanese physicians concerning withholding and withdrawal of life-sustaining treatment for end-of-life patients: results from an Internet survey

The case scenarios used in the survey

Case 1

An 84-year-old man with mild dementia at the outset and Level 3 care requirement* for daily living, hospitalized for unilateral paralysis in conjunction with loss of consciousness due to left internal carotid artery embolism. Life was preserved in the acute phase, but the patient is wholly incapable of coherent conversation at 6 days after admission. The patient is completely bedridden and requires a change of position every few hours. There is pooling of saliva and sputum in the mouth, and oral suctioning is performed approximately 10 times per day. The administration of enteric nutritional agents as part of the nutritional management is required to maintain the nutritional status. When the administration of these nutritional agents via nasogastric intubation or the creation of a gastrostomy was explained to the family, their response was, "As long as he will not suffer, we will leave the decision to you." There is no information from which to infer the prior wishes of the patient.

*Level 3 care requirement means the requirement of support from others for daily bathing and toileting according to the category decided by the Ministry of Health, Labour and Welfare. They cannot stand up and walk by themselves.

Question 1: "What do you think should be done with regard to the initiation of enteric feeding for the aforementioned patient?"

Question 2: "What do you do with regard to the initiation of enteric nutrition for such a type of patient?"

Case 2

An 84-year-old man hospitalized for unilateral paralysis in conjunction with loss of consciousness due to internal carotid artery embolism, with the clinical progress in the acute phase the same as in Case 1. Enteric nutrition was initiated by nasogastric intubation on day 6. The paralysis and state of consciousness remained unchanged, and the overall condition stabilized as bedridden, with regular administration of enteric nutrition alone apart from several drugs given. The respiratory status deteriorated abruptly on day 20 of admission, and major aspiration pneumonia was developed. Hypoxemia and labored breathing developed, and the attachment to an artificial respirator became necessary for life saving and recovery. Complete recovery from pneumonia may be possible, but attachment to the artificial respirator for several weeks is required, and depending on the circumstances, tracheotomy may be necessary. The family has again responded, "As long as he will not suffer, we will leave the decision to you."

Question 3: "What do you think should be done with regard to the attachment of an artificial respirator for such a type of patient?"

Question 4: "What do you do with regard to the attachment of an artificial respirator for such a type of patient?"

Case 3

An 84-year-old man hospitalized for unilateral paralysis in conjunction with loss of consciousness due to internal carotid artery embolism, with the clinical progress in the acute phase the same as in Cases 1 and 2. Tube feeding was initiated by nasogastric intubation on day 6. The paralysis and state of consciousness remained unchanged, and the overall condition stabilized as bedridden. A gastrostomy was then performed, and the patient was transferred to a recuperative unit on day 28. After 6 months, the patient was bedridden, unable to communicate his will, and was in a state still requiring oral suctioning 10 times per day and changes of position several times a day. On a certain day, the routine visitors from the family (the wife and the oldest son) made a request to you as the ward physician: "We cannot go on seeing him suffer; we would like you to remove the feeding tube."

Question 5: "In circumstances similar to those described above, do you think that enteric nutrition should be withdrawn pursuant to a family request?"

Question 6: "What do you do regarding the withdrawal of artificial nutrition in cases such as the one described above?"